RS Signs Flashcards
Pulse
Paradoxical- respiratory distress
Bounding- CO2 rention.
Face
Ptosis and constricted pupil- horners eg pancoast tumour.
Blue tongue and lips- central cyanosis.
Pale conjunctiva- anaemia.
Tracheal displacement
Towards collapse or UNILATERAL fibrosis or lung removal.
Away from large pleural effusion or tension pneumothorax.
Slight R deviation normal.
Cricosternal distance over 3cm- hyperexpansion.
Tracheal tug on inspiration- severe airflow restriction.
Lymphadenopathy
CA
TB
Raised JVP
Cor pulmonale
Apex beat
Impalpable- COPD, pleural effusion, dextrocardia.
Expansion
Under 5cm on deep inspiration abnormal. Should be symmetrical. -unilaterally low- Pneumonia, pneumothorax, pleural effusion, lobar collapse. -bilateral- ILD stiffness, hyperinflation.
Percussion
Dull- collapse, consolidation, fibrosis, pleural thickening, pleural effusion STONY DULL.
Hyperresonant- pneumothorax or hyperinflation (COPD).
Breath sounds
- Normal vesicular rustling
- Brochial breathing- harsh with gap between inspiration and expiration. Occurs in firm lung tissue eg consolidation (pneumonia), fibrosis, above a pleural effusion, large pericardial effusion. May have increased vocal resonance too.
- Diminished breath sounds- pleural effusion, pleural thickening, oneumothorax, bronchial obstruction, asthma, COPD.
- Silent- life threatening asthma.
- Wheeze- monophonic if partial obstruction of one airway eg tumour.
Polyphonic if widespread narrowing of differing calibre eg asthma, COPD. Also LVF cardiac asthma.
-Crackles/crepitations- caused by re opening during inspiration of small airways occluded during expiration.
Fine and late in inspiration if coming from distal air spaces eg pulmonary oedema, fibrosing alveolitis.
Coarse in mid inspiration if proximal eg bronchiectasis.
In early inspiration if small airways disease eg COPD.
Late or pan inspiration if alveolar disease.
-stridor- part obstruction upper airways. Lumen, wall or extrinsic. - Pleural rubs- inflammatory exudate roughens pleural surfaces eg pneumonia, pulmonary infarction.
- loud clear vocal resonance if consolidation (brochial breathing).
Decreased vocal resonance if pneumothorax, pleural effusion.
Normal is muffled.
Hyperventilation- fast or deep.
Can lead to respiratory alkalosis and hence parasthesia.
Main cause in anxiety.
- kussmaul deep sighing in metabolic acidosis eg DM or alphoholic ketoacidosis, renal impairment.
- neurogenic- pontine lesions.
- hyperventilation syndrome panic attacks
Cheyne stokes deeper then shallower in cycles
brainstem lesions or compression eg RICP, stroke.
Sputum
- black carbon specks- smoking.
- yellow or green- infection eg bronchiectasis, pneumonia.
- pink frothy- pulmonary oedema.
- haemoptysis- malignancy, TB, infection, trauma.
Deformities
- barrell chest AP diameter, reduced expansion, tracheal descent- chronic hyperinflation eg COPD, asthma.
- pectus carinatum sternal prominence - lung hyperinflation while thorax still developing eg chronic childhood asthma.
- pectus exacavatum lower sternal depression- developmental defect. Associated with scoliosis, marfans and ehlers. Can cause heart displacement and reduced capacity.
- kyphosis increased AP T spine curvature.
- scoliosis- lateral curvature.
Stridor inspiration
Partial obstruction upper airways.
In lumen eg FB, tumour, VC palsy.
In wall eg oedema, laryngospasm, tumour, croup, epiglittitis, amyloidosis.
Extrinsic eg goitre, oesophagus, lymphadenopathy, post op.
Cough
- loud brassy- pressure on trachea eg tumour.
- hollow bovine- RLN palsy.
- barking- croup.
- chronic- pertissis, TB, FB, asthma.
- dry chronic- oesophageal reflux, ACEi.
- painful
- throat clearing
Under 3 weeks- RTI
Over 3 weeks- COPD, asthma, CA, meds eg ACEi
Haemoptysis
Frothy, alkaline, bright red
- infective- TB, brochiectasis, pneumonia, abcess, COPD, fungus, virus (pneumonitis, hep, HIV), helminth, bronchitis.
-pulmonary oedema-frothy pink. - neoplastic- primary or secondary
- vascular- PE, vasculitis, HHT, AVM, capillaritis.
- parenchymal- fibrosis, sarcoidosis, haemosiderosis, CF.
- pulmonary HTN- idiopathic, TE, cyanotic CHD, fibrosis, bronchiesctasis.
- caogulopathy- thrombocytopenia, warfarin.
- trauma or FB- post intubation, eroding defib.
Find out how much
Differentiate from haematemesis.
Dyspnoea-
Awareness that abnormal effort to breathe
- lung
- cardiac- IHD, LVF, MV stenosis.
- anatomical- chest wall, muscle or pleura disease. Ascites.
- other- shock, anaemia, respiratory acidosis.
ACUTE- FB, pneumothorax, PE, acute pulmonary oedema.
SUBACUTE- asthma, parenchymal disease eg alveolitis pneumonia.
CHRONIC- COPD, HF, anaemia.
Signs- accessory muscle, tracheal tug, nasal flaring, sternal retraction, intercostal recession, tripoding.
-Qs- onset duration, how long for, how much exercise, previous heart/lung issues, fever, smoke, pain.
-differentials- unfit, infection, efffusion, COPD, asthma.
General inspection
COINS Chest drain O Inhalers News Sputum pot Breathing, accessory muscles, colour etc.
Horners
T1 lesion due to pancoast tumour (brochial carcinoma) in lung apex compressing sympathetic chain. Intrinsic muscle wasting Ptosis Anhydrosis Mitosis
Pleural effusion signs
Reduced expansion Stony dull percussion Reduced air entry Reduced vocal resonance Veiscaular breath sounds, reduced intensity on affected side. Tracheal deviation away if large
Consolidation signs
Consolidation- fluid inside alveoli
Effusion- fluid in pleural space
Reduced expansion
Dull percussion
Increased vocal resonance
Bronchial breathing, possible coarse crackles.
Collapse signs
Due ot large airway obstruction eg CA
Reduced expansion on affected side Dull or normal percussion Reduced breath sounds on affected side Trachea deviation towards Reduced vocal resonance
Pneumothorax signs
Reduced expansion
Hyperresonance
Reduced breath sounds, cab be absent in tension
Trachea deviated away from tension pneumothorax
Reduced vocal resonance
Fibrosis signs
Reduced expansion on affected side(s) Dull or normal percussion Fine inspiratory crackles Trachea pulled towards unless bilateral fibrosis. Vesicular breath sounds Normal or increaed vocal resonance FEV1/FVC normal but FVC very low Low diffusion capacity
Cause of exudative effusion
Inflammation
Infection
??
Causes of transudative effusion
HF
??
Virchows triad
Vessel wall
Blood components
Blood flow
HF vs DVT
DVT unilateral
HF- pitting oedema and bilateral and worse through day.
DVT- pain, red, hot, tender
Horners syndrome
Triad- miosis (pupil constriction), partial ptosis, ipsilateral anhidrosis (lack sweat).
Interrupted face SNS supply eg at throacic outlet (pancoast tumour). Or brainstem, SC, ICA hitchhike.
Pancoast syndrome
Apical lung CA invades SNS plexus in neck.
Can= ipsilateral horners, brachial plexus lesion, RLN lesion.
Sarcoidosis
Multisystem non caseating granulomtous disorder. Unknown cause. Afro carribean and asian.
Usually asymptomatic, can get cough or rash. Acute= erythema nodosum.
Lungs- pulmonary lymphadenopathy and infiltration/fibrosis.
Other- lymphadenopathy, hepatomegaly, splenomagaly, conjunctivitis, glaucoma, bone cyst, bell splasy, meningitis, SOL, renal stones, pituitary dysfunction.
Tx- rest and NSAIDs. Occasionally steroids or methotrexate.
Differentials- lymphoma, TB.
Stridor
Luminal- FB, tumour, VC palsy
In wall- anaphylaxis oedema, laryngospasm, tumour, croup, epgilottitis, amyloidosis.
Extrinsic- goitre, oesophagus, LN, post op.
Type 2 respiratory depression causes
- respiratory depression- head injury, drugs.
- muscle weakness- SC injury, peripheral neuropathy, NMJ, myopathy.
- chest wall problems- obesity.
- lungs difficult to ventilate- late acute asthma, COPD, fibrosis.
Type 1 respiratory failure causes
V/Q mismatch (hyperventilation cannot increase O content)
- early acute asthma- V/Q mismatch.
- PE- V/Q mismatch.
- fibrosing alveolitis- increase diffusion distance. Affects O more as lower solubility.
Central cyanosis oral mucosa or tongue
Arterial sats under 90%
PO2 8kPa
Hyperinflation
More than 6 anterior ribs seen.
Flat hemidiaphragms.
Ribs more horizontal.
Normally in full inspiration diaphragm crosses 6th rib anteriorly.
T1 respiratory failure- low arterial O, normal/low CO2 as hypoxia stimulated RR
Mechanism-
Poor diffusion across alveoli-
-fibrosis increase distance
-emphysema decrease sa
V/Q mismatch
-reduced ventilation to part of lung (V/Q under 1)- pneumonia, acute severe asthma, RDS.
-reduced perfusion of part of lung (V/Q under 1)- PE.
T2 respiratory failure- low O AND high CO2
Mechanism-
Ventilation pump failure- hypoventilation.
Causes of T2 failure-
-primary muscle disorder- myopathy, MND
-chest walls problems-obesity, kyphoscoliosis, flail segment
-poor lung compliance- fibrosis.
-high airway resistance- severe acute asthma, late COPD.
Other causes hypoventilation-
-brainstem respiratory depression- head injury, opiates.
-SC trauma
-phrenic and ICN- guillain barre
-NMJ-MG
-pleural cavity- pneumothorax, large pleural effusion.
-upper airway obstruction- laryngeal oedema, FB.
Acute effects-
SOB
Acidosis
Usually requires assisted ventilation
PE consequences
T1 respiratory failure
RHF
Reduced CO
Hypoxia
-Causes: Respiratory failure causes Low inspired O R to L shunts -clinical features: Excercise intolerance Tachypnoea Confusion Central cyanosis when sats under 85% -chronic= Increase Hb Increase 23DPG Hypoxic vasoconstriction pulmonary arterioles= pulmonary HTN, RHF.
URT flora
-Common- Strep viridans Neiseria sp Anaerobes Candida -less common Strep pneumoniae and pyogenes H influenzae Pseudomonas Ecoli
CAP
Organisms- strep pneumoniae, H influenzae, moraxella catarrhalis.
Tx- likely pneumococcal so pen.
Mild to moderate give amoxicillin OR doxycycline.
Moderate to severe give co amoxiclav AND doxycycline.
Pneumonia general
Symptoms- SOB, cough maybe yellow or rusty sputum, fever, rigors, pleuritic pain, malaise, nausea, vomiting.
Signs- pyrexia, tachyc/p, cyanosis, dull, bronchial breathing, crackles.
Investigation- all bloods, CXR, swabs and cultures, biopsy, BAL, serum Ab.
Tx- fluid, O, analgesia, antipyretic, AB.
Outcome- resolution scarring, abcess, bronchiestasis, empyema.
Atypical pneumonia
Legionella
Mycoplasma
Chlamydia
CURB score
Confusion Urea over 7 RR over 30 BP under 90/60 Score of 2 consider admission. 2-5 means severe, admit.
Viral pneumonia
Influenza
Parainfluenza
RSV
Adenovirus
HAP
Sa Pseudomonas H influenzae Enterobacteria Tx- co amoxiclav as more gram negs
Aspiration pneumonia
Strep viridans
Anaerobes
Tx- co amoxiclav.
Immunosuppressed pneumonia
PCP
Aspergillus
CMV
TB pathogenesis
Inhaled aerosol
Alveolar macrophage engulf
Local LNs= primary complex (ghons focus+draining LN)
Then either progression to active PRIMARY disease OR initial containment then latent infection then cure or POST PRIMARY TB.
Granuloma
Core caseous necrosis
Epitheloid macrophage
Multi nucleated langhans giant cells
Lymphocytes
Latent TB-inactive, contained
Reactivation eg age, malnutrition, HIV, immunosuppresion, steroids, substance abuse, lymphoma, DM.
Gives positive tuberculin skin test- TIV hypersensitivity to mycobacterial protein. Also positive IFNg.
CXR normal, sputum smear and culture negative, no symptoms, not infectious.
Extra pulmonary TB
Larynx LNs Pleura Brain- TB meningitis Kidneys to lower UT Peritoneum Bones eg spine Miliary- carried everywhere in blood= headache, pleural/pericardial effusion, ascites, retinal.
TB general
Hx- travel, ethnicity, immunocompromise, homeless, drug, contacts, BCG
Symptoms- fever, weight loss, malaise, anorexia, night sweats, cough sometimes blood, SOB if pleural effusion.
Signs- fever, weight loss, maybe crackles, CXR caviatation/fibrosis, pleural effusion.
Investigation- CXR (solid or cavitation lesion, streaky fibrosis, calcification, often apex, pleural effusion if bad), sputum 3 early ZN stain and culture and granuloma histology, bronchoscopy, TST, iFNg.
TB tx
1st line- -rifampicin- CYP induction, increase AST/LT, orange. -isoniazid- peripheral neuropathy, hepatotoxicity. -pyrazinamide- hepatotoxicity. -ethambutol- visual disturbance. Give all for 2/12 then 1st 2 for 4/12. 2nd line- quinolones etc. Also vit D, surgery. Poor compliance. Contacts.
Lung CA RFs
Smoking Asbestos Radon Occupational carcinogens eg nickel, arsenic Genetic
Lung CA staging
T=tumour- size, location in lung, number N=LNs- hilar, same side, above clavicle M= mets within chest or outside Local spread in chest- draining LN, pericardium, pleura, other lung. Distant- brain, liver, adrenals, bone
Lung cancer S+S
-Symptoms-
Primary tumour- NONE, cough, SOB, wheeze, haemoptysis, infections, pain, weight loss, malaise.
Regional mets- bloated face SVC obstruction, hoarse voice, dysphagia, CP
Distant mets- bone pain or fractures, CNS eg heache, vision, confusion.
Metabolic- thirst and constipation if hyperCa, seizure if hypoNa.
-signs-
Clubbing
Cachexia
Dysphagia
Pale conjunctiva
Cervical lymphadenopathy
Horners, hoarse voice, lower brachial plexus.
Consolidation
Persistent pneumonia
Partial obstruction- monophonic wheeze, stridor, infection distal to tumour. Complete bronchi obstruction- distal collapse.
Pleural effusion
Muffled heart sounds
Hepatomegaly
Skin mets
Neuro long tract signs
NONE
Lung CA types
Carcinoma= invasive malignant epithelial tumour -non small cell- Squamous cell carcinoma 40% Adenocarcinoma 35% Large cell carcinoma 5% -small cell carcinoma- 12% -rare eg carcinoid- 5%
Lung CA investigation
-Molecular markers:
EGFR mutation
KRAS mutation
ALK mutation
PD1 mutation
-bronchoscopy, biopsy, imaging, pleural fluid analysis, other mets tests, FBC, CRP, blood serology, sputum culture, lung function.
-pleural fluid- protein, microscopy, cytology (CA).
Lung CA performance status
0- no symptoms, normal activities. 1- symptoms but normal ADLs. 2- symptoms and bed/chair under half day. 3- symptoms and bed/chair over half day. 4- bedridden 5-dead Radical tx requires 2+
Lung CA tx
Surgery- mostly non small cell. Radiotherapy- radical or palliative. Combination chemo- small or non small cell, neo or adjuvant. Combination therapy- chemo+ radio. Biological- based on mutation. Palliative
Pack years
Number of packs per day (20 a pack) x number of years smoked
CXR
Normal anterior 5th-7th rib MCL.
Silhouette sign for seeing consolidation.
Lingula= part of L upper lobe.
Mediastinal push- pleural effusion, tension pneumothorax.
Pull- fibrosis, collapse, previous surgery.
Cardiac index normal over 50% on PA. AP exaggerates heart size.
DR ABCDE
D- details/demographics
R- RIPE (rotation, inspiration, penetration, everything visible that should be?).
A-airway
B-breathing (lung zones)
C-circulation/central (mediastinum and heart)
D-diaphragm
E-everything else eg bone soft tissue
Pneumothorax CXR
Large if over 2cm bewteen inner chest wall and lung.
Mediastinal push.
Can be spontaneous, secondary to eg CA or COPD, iatrogenic eg central line.
Tx- aspiration or chest drain. Chemical pleurodesis. Pleurectomy. O.
Tension- tachyc, hypotension, reduced expansion, hyper resonance, mediastinal push, hypoxaemia.
Pleural effusion CXR
Fluid in pleural space. White uniform. Loss costophrenic angle. Hemidiaphragm obscured. Meniscus Tracheal push
Lobar collapse CXR
Elevated hemidiaphragm ipsilaterally and rib crowding.
Mediastinal pull.
Pulmonary vessel crowding.
VAIL L upper lobe.
SAIL L lower lobe. Complete occlusion lower lobe bronchus.
Whole lung collapse- homogenous opacification entire side and tracheal pull.
Consolidation CXR
Pus/blood/fluid/cell to alveoli.
Dense opacification.
ILD S+S
Symptoms-
SOB chronic onset, decrease exercise tolerance, dry cough.
Signs-
Tachypnoea, bilateral reduced expansion, coarse crackles, cyanosis, RHF signs, clubbing in cryptogenic fibrosing alveolitis.
ILD types
Occupational- asbestosis, silicosis, coal pneumoconiosis.
Tx- radiation, methotrexate, amiodarone, nitrofurantoin, chemo, bleomycin.
CT disease- RA, SLE, scleroderma.
Immunological- sarcoidosis, hypersensitivity pneumonitis.
Idiopathic- cryptogenic fibrosing alveolitis, idiopathic pulmonary fibrosis.
ILD fibrosing alveolitis
Infection or pollution trigger alveolar mac then cascade.
ROS and protease damage.
Small nodules, lower lobes, fine crackles.
Tx- oral steroid, monitor LFTs.
ILD extrinsic allergic alveolitis
Inhalation organic matter=allergic reaction in small airway and alveolar walls.
Acute eg farmers lung actinomycetes. Diffuse nodules hila.
Chronic eg bird fancier. Upper fibrosis.
ILD idiopathic pulmonary fibrosis
Median survival 3 years
New mAb therapies.
Asbestos
Plaques Diffuse pleural thickening Benign asbestos pleural effusion Asebstosis Mesothelioma Bronchogenic lung CA Rounded atelectasis
Pleura
-pleural space function-
Allow movement of lung against wall
Couple movement of lung and wall
Pleural fluid circulation- 15ml per day made by parietal pleura capillary filtration, absorbed by parietal lymphatic stomata.
-innervation
Parietal phrenic and ICN so pleuritic pain sharp and worse on inspiration.
Visceral no somatic
-pleuritic pain
Can be anywhere in chest, sharp, worse on inspiration or cough, may have secondary symptoms.
Causes- lobar pneumonia, PE, infarction, pneumothorax.
Pleural fluid accumulation
Increase pulmonary intravascular pressure eg HF.
Decrease plasma oncotic pressure eg liver fail.
Increase capillary permeability eg inflammation or CA.
Lymphatic obstruction.
Trans and exudate
Exudate of high protein and LDH.
Get fluid by thoracocentesis- test appearance, cell count and differentiation, protein, LDH, pH, glucose, cytology.
-transudate- HF, nephrotic syndrome, cirrhosis, hypoalbumin.
-exudate- infection, malignancy, RA, PE, pancreatitis.
-empyema- infection. low pH, low glucose. Get adhesions and loculations.
-haemothorax- trauma, iatrogenic.
-chylothorax- milky. Lymphatic interruption, lymphoma, iatrogenic, trauma.
Pleural CA
Mets- lung, breast, kidney, colon.
Primary- mesothelioma. Dull diffuse CP, often effusion.
Airway obstruction
Monophonic wheeze
Pneumonia distally
Collapse if complete obstruction
Pneumonia CXR
Patchy opacification, often upper lobe.
TB CXR
Patch opacification often both upper zones
Horizontal fissure appears high
Cavities
Solitary hilar mass CXR
CA
Infection
Benign tumour
CT disease eg RA
Pulmonary oedema CXR
Bilateral ill defined peri hilar shadowing- bat wings
Cardiac enlargement
MRC dyspnoea scale
1-SOB on strenuous exercise
2-SOB when hurrying on level or slight hill.
3-walk slower or has to stop
4-stop after 100yards or few mins on level.
5-cant leave house.
Wheeze expiration
Asthma
COPD
FB
Hoarse voice
Transient inflammation vocal cords
Vocal cord tumour
RLN palsy- L side long course, can be damaged by bronchial carcinoma.
Drug hx
ACEi cough
beta blocker wheeze
Oestrogens PE
Amiodarone fibrosis
Social hx
Smoking
Occupation
ADLs, stairs at home
Intrinsic hand muscle wasting
T1 root compression by peripheral lung tumour eg pancoast
COPD or asthma signs
Barrel chest
Reduced expansion as hyperinflated
Resonant percussion, hyper resonant over bullae, liver lower
Vesicular breath sounds with prolonged expiration and wheeze
Pleura surface markings (costal cartilages)
-apex extends 3 cm above medial 1/3 of clavicle, into root of neck. Apical pleura covered by fascia (subpleural membrane) which is attached to inner border of 1st rib.
-then pleura meet at 2nd CC
(2nd CC articulates with sternum at sternal angle)
-Then down to 4th CC
-then L pleura deviates laterally to edge of sternum then down to 6th CC. R pleura just goes straight down to 6th CC.
-then both sides turn laterally, crossing 8th rib at mid clavicular line.
-cross 10th rib at mid axillary and 12th in scapular line.
-to the lateral edge of paravertebral muscles and vertically up to apex.
Lung surface markings (ribs)
Lower border 2 ribs higher than pleural.= costodiaphragmatic recess.
- so crosses 6th rib at mid clavicular line, 8th at mid axillary, 10th scapular line and lateral paravertebral muscles.
- cardiac notch curves further laterally than pleura- from 4th CC to 5th ICS just medial to mid clavicular line.
Lung fissures
- L oblique fissure separates upper and lower lobes.
- R horizontal separates upper and middle. Oblique separates middle and lower.
- oblique fissure on each side extends from T2 process posteriorly to 6th CC anteriorly.
- horizontal fissure on R extends from mid axillary, anteriorly along 4th rib.
Diaphragm
Right dome at 5th rib.
Left dome lower at 5th ICS.
Precussion and surface markings
Dull below 5th rib due to:
-liver as is only overlapped by very thin lung.
-costodipahragmatic recess.
Resonance below 5th rib is sign of hyper inflation eg COPD.
